Provider Demographics
NPI:1427108455
Name:FISHER, WILLIAM R (PA-C)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:R
Last Name:FISHER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 320
Mailing Address - Street 2:
Mailing Address - City:SILETZ
Mailing Address - State:OR
Mailing Address - Zip Code:97380-9673
Mailing Address - Country:US
Mailing Address - Phone:541-444-1030
Mailing Address - Fax:541-444-9695
Practice Address - Street 1:200 GWEE SHUT ROAD
Practice Address - Street 2:
Practice Address - City:SILETZ
Practice Address - State:OR
Practice Address - Zip Code:97380-9673
Practice Address - Country:US
Practice Address - Phone:541-444-1030
Practice Address - Fax:541-444-9695
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00993363A00000X
MP84363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q36842Medicare UPIN
ORQ36842Medicare UPIN